NR 464 - Exam 3 (Saunders) Test Questions and
Answers Rated A+
The nurse provides home care instructions to a from infection
client with systemic lupus erythematosus and
tells the client about methods to manage fatigue.
Which statement by the client indicates a need The client with acquired immunodeficiency
for further instruction? syndrome is diagnosed with cutaneous Kaposi's
sarcoma. Based on this diagnosis, the nurse
1. "I should take hot baths because they are understands that this has been confirmed by
relaxing." which finding?
2. "I should sit whenever possible to conserve 1. Swelling in the genital area
my energy."
2. Swelling in the lower extremities
3. "I should avoid long periods of rest because it
causes joint stiffness." 3. Positive punch biopsy of the cutaneous lesions
4. "I should do some exercises, such as walking, 4. Appearance of reddish-blue lesions noted on
when I am not fatigued." - ANSWER -1. "I the skin - ANSWER -3. Positive punch
should take hot baths because they are biopsy of the cutaneous lesions
relaxing."
Kaposi's sarcoma lesions begin as red, dark blue,
To help reduce fatigue in the client with systemic or purple macules on the lower legs that change
lupus erythematosus, the nurse should instruct into plaques. These large plaques ulcerate or
the client to sit whenever possible, avoid hot open and drain. The lesions spread by
baths (because they exacerbate fatigue), metastasis through the upper body and then to
schedule moderate low-impact exercises when the face and oral mucosa. They can move to the
not fatigued, and maintain a balanced diet. The lymphatic system, lungs, and gastrointestinal
client is instructed to avoid long periods of rest tract. Late disease results in swelling and pain in
because it promotes joint stiffness. the lower extremities, penis, scrotum, or face.
Diagnosis is made by punch biopsy of cutaneous
lesions and biopsy of pulmonary and
The nurse is assisting in planning care for a gastrointestinal lesions.
client with a diagnosis of immunodeficiency and
should incorporate which action as a priority in
the plan? The home care nurse is preparing to visit a client
who has undergone renal transplantation. The
1. Protecting the client from infection nurse develops a plan of care that includes
monitoring the client for signs of acute graft
2. Providing emotional support to decrease fear rejection. The nurse documents in the plan to
assess the client for which signs of acute graft
3. Encouraging discussion about lifestyle rejection?
changes
1. Fever, hypotension, and polyuria
4. Identifying factors that decreased the immune
function - ANSWER -1. Protecting the client 2. Hypertension, polyuria, and thirst
,NR 464 - Exam 3 (Saunders) Test Questions and
Answers Rated A+
2. Emboli
3. Fever, hypertension, and graft tenderness
3. Facial rash
4. Hypotension, graft tenderness, and
hypothermia - ANSWER -3. Fever, 4. Two hemoglobin S genes - ANSWER -3.
hypertension, and graft tenderness Facial rash
Systemic lupus erythematosus is a chronic,
A client with acquired immunodeficiency progressive, inflammatory connective tissue
syndrome (AIDS) has been started on therapy disorder that can cause major body organs and
with zidovudine. The nurse should monitor the systems to fail. A butterfly rash on the cheeks
results of which laboratory blood study for and bridge of the nose is an essential sign of
adverse effects of therapy? SLE. Ascites and emboli are found in many
conditions but are not associated with SLE. Two
1. Creatinine level hemoglobin S genes are found in sickle cell
anemia.
2. Potassium concentration
3. Complete blood cell (CBC) count A client has requested and undergone testing for
human immunodeficiency virus (HIV) infection.
4. Blood urea nitrogen (BUN) level - The client asks what will be done next because
ANSWER -3. Complete blood cell (CBC) the result of the enzyme-linked immunosorbent
count assay (ELISA) has been positive. Which
diagnostic study should the nurse be aware of
Acquired immunodeficiency syndrome is a viral before responding to the client?
disease caused by the human immunodeficiency
virus (HIV), which destroys T cells, thereby 1. No further diagnostic studies are needed.
increasing susceptibility to infection and
malignancy. Common adverse effects of 2. A Western blot will be done to confirm these
zidovudine are agranulocytopenia and anemia. findings.
The nurse should monitor the CBC count for
these changes. Creatinine, potassium, and BUN 3. The client probably will have a bone marrow
are unrelated to this medication. biopsy done.
4. A CD4+ cell count will be done to measure T
The nurse is performing an assessment on a helper lymphocytes. - ANSWER -2. A
female client who complains of fatigue, Western blot will be done to confirm these
weakness, muscle and joint pain, anorexia, and findings.
photosensitivity. Systemic lupus erythematosus
(SLE) is suspected. What should the nurse
further assess for that also is indicative of SLE? The nurse is caring for a client with acquired
immunodeficiency syndrome and detects early
1. Ascites infection with Pneumocystis jiroveci by monitoring
the client for which clinical manifestation?
, NR 464 - Exam 3 (Saunders) Test Questions and
Answers Rated A+
The client experiences dyspnea, fever, cough,
1. Fever and weight loss. The remaining options are
incorrect.
2. Cough
3. Dyspnea at rest The nurse is caring for a client with acquired
immunodeficiency syndrome (AIDS) who is
4. Dyspnea on exertion - ANSWER -2. experiencing night fever and night sweats. Which
Cough nursing interventions would be helpful in
managing this symptom? Select all that apply.
Pneumocystis jiroveci pneumonia (PCP) is a
fungal infection and is a common opportunistic 1. Keep liquids at the bedside.
infection. The client with P. jiroveci infection
usually has a cough as the first sign. The cough 2. Place a towel over the pillowcase.
begins as nonproductive and then progresses to
productive. Later signs and symptoms include 3. Make sure the pillow has a plastic cover.
fever, dyspnea on exertion, and finally dyspnea
at rest. 4. Keep a change of bed linens nearby in case
they are needed.
A client with acquired immunodeficiency 5. Administer an antipyretic after the client has a
syndrome (AIDS) has a concurrent diagnosis of spike in temperature. - ANSWER -1. Keep
histoplasmosis. During the assessment, the liquids at the bedside.
nurse notes that the client has enlarged lymph
nodes. How should the nurse interpret this 2. Place a towel over the pillowcase.
assessment finding?
3. Make sure the pillow has a plastic cover.
1. The histoplasmosis is resolving.
4. Keep a change of bed linens nearby in case
2. The client has disseminated histoplasmosis they are needed.
infection.
For clients with AIDS who experience night fever
3. This is a side effect of the medications given to and night sweats, the nurse may offer the client
treat AIDS. an antipyretic of choice before the client goes to
sleep rather than waiting until the client spikes a
4. The client probably has another infection that temperature. Keeping a change of bed linens and
is developing. - ANSWER -2. The client has night clothes nearby for use also is helpful. The
disseminated histoplasmosis infection. pillow should have a plastic cover, and a towel
may be placed over the pillowcase if diaphoresis
Histoplasmosis is caused by Histoplasma is profuse. The client should have liquids at the
capsulatum and usually starts as a respiratory bedside to drink.
infection in the client with AIDS and then
becomes a disseminated infection, with
enlargement of lymph nodes, spleen, and liver. A client with acquired immunodeficiency
Answers Rated A+
The nurse provides home care instructions to a from infection
client with systemic lupus erythematosus and
tells the client about methods to manage fatigue.
Which statement by the client indicates a need The client with acquired immunodeficiency
for further instruction? syndrome is diagnosed with cutaneous Kaposi's
sarcoma. Based on this diagnosis, the nurse
1. "I should take hot baths because they are understands that this has been confirmed by
relaxing." which finding?
2. "I should sit whenever possible to conserve 1. Swelling in the genital area
my energy."
2. Swelling in the lower extremities
3. "I should avoid long periods of rest because it
causes joint stiffness." 3. Positive punch biopsy of the cutaneous lesions
4. "I should do some exercises, such as walking, 4. Appearance of reddish-blue lesions noted on
when I am not fatigued." - ANSWER -1. "I the skin - ANSWER -3. Positive punch
should take hot baths because they are biopsy of the cutaneous lesions
relaxing."
Kaposi's sarcoma lesions begin as red, dark blue,
To help reduce fatigue in the client with systemic or purple macules on the lower legs that change
lupus erythematosus, the nurse should instruct into plaques. These large plaques ulcerate or
the client to sit whenever possible, avoid hot open and drain. The lesions spread by
baths (because they exacerbate fatigue), metastasis through the upper body and then to
schedule moderate low-impact exercises when the face and oral mucosa. They can move to the
not fatigued, and maintain a balanced diet. The lymphatic system, lungs, and gastrointestinal
client is instructed to avoid long periods of rest tract. Late disease results in swelling and pain in
because it promotes joint stiffness. the lower extremities, penis, scrotum, or face.
Diagnosis is made by punch biopsy of cutaneous
lesions and biopsy of pulmonary and
The nurse is assisting in planning care for a gastrointestinal lesions.
client with a diagnosis of immunodeficiency and
should incorporate which action as a priority in
the plan? The home care nurse is preparing to visit a client
who has undergone renal transplantation. The
1. Protecting the client from infection nurse develops a plan of care that includes
monitoring the client for signs of acute graft
2. Providing emotional support to decrease fear rejection. The nurse documents in the plan to
assess the client for which signs of acute graft
3. Encouraging discussion about lifestyle rejection?
changes
1. Fever, hypotension, and polyuria
4. Identifying factors that decreased the immune
function - ANSWER -1. Protecting the client 2. Hypertension, polyuria, and thirst
,NR 464 - Exam 3 (Saunders) Test Questions and
Answers Rated A+
2. Emboli
3. Fever, hypertension, and graft tenderness
3. Facial rash
4. Hypotension, graft tenderness, and
hypothermia - ANSWER -3. Fever, 4. Two hemoglobin S genes - ANSWER -3.
hypertension, and graft tenderness Facial rash
Systemic lupus erythematosus is a chronic,
A client with acquired immunodeficiency progressive, inflammatory connective tissue
syndrome (AIDS) has been started on therapy disorder that can cause major body organs and
with zidovudine. The nurse should monitor the systems to fail. A butterfly rash on the cheeks
results of which laboratory blood study for and bridge of the nose is an essential sign of
adverse effects of therapy? SLE. Ascites and emboli are found in many
conditions but are not associated with SLE. Two
1. Creatinine level hemoglobin S genes are found in sickle cell
anemia.
2. Potassium concentration
3. Complete blood cell (CBC) count A client has requested and undergone testing for
human immunodeficiency virus (HIV) infection.
4. Blood urea nitrogen (BUN) level - The client asks what will be done next because
ANSWER -3. Complete blood cell (CBC) the result of the enzyme-linked immunosorbent
count assay (ELISA) has been positive. Which
diagnostic study should the nurse be aware of
Acquired immunodeficiency syndrome is a viral before responding to the client?
disease caused by the human immunodeficiency
virus (HIV), which destroys T cells, thereby 1. No further diagnostic studies are needed.
increasing susceptibility to infection and
malignancy. Common adverse effects of 2. A Western blot will be done to confirm these
zidovudine are agranulocytopenia and anemia. findings.
The nurse should monitor the CBC count for
these changes. Creatinine, potassium, and BUN 3. The client probably will have a bone marrow
are unrelated to this medication. biopsy done.
4. A CD4+ cell count will be done to measure T
The nurse is performing an assessment on a helper lymphocytes. - ANSWER -2. A
female client who complains of fatigue, Western blot will be done to confirm these
weakness, muscle and joint pain, anorexia, and findings.
photosensitivity. Systemic lupus erythematosus
(SLE) is suspected. What should the nurse
further assess for that also is indicative of SLE? The nurse is caring for a client with acquired
immunodeficiency syndrome and detects early
1. Ascites infection with Pneumocystis jiroveci by monitoring
the client for which clinical manifestation?
, NR 464 - Exam 3 (Saunders) Test Questions and
Answers Rated A+
The client experiences dyspnea, fever, cough,
1. Fever and weight loss. The remaining options are
incorrect.
2. Cough
3. Dyspnea at rest The nurse is caring for a client with acquired
immunodeficiency syndrome (AIDS) who is
4. Dyspnea on exertion - ANSWER -2. experiencing night fever and night sweats. Which
Cough nursing interventions would be helpful in
managing this symptom? Select all that apply.
Pneumocystis jiroveci pneumonia (PCP) is a
fungal infection and is a common opportunistic 1. Keep liquids at the bedside.
infection. The client with P. jiroveci infection
usually has a cough as the first sign. The cough 2. Place a towel over the pillowcase.
begins as nonproductive and then progresses to
productive. Later signs and symptoms include 3. Make sure the pillow has a plastic cover.
fever, dyspnea on exertion, and finally dyspnea
at rest. 4. Keep a change of bed linens nearby in case
they are needed.
A client with acquired immunodeficiency 5. Administer an antipyretic after the client has a
syndrome (AIDS) has a concurrent diagnosis of spike in temperature. - ANSWER -1. Keep
histoplasmosis. During the assessment, the liquids at the bedside.
nurse notes that the client has enlarged lymph
nodes. How should the nurse interpret this 2. Place a towel over the pillowcase.
assessment finding?
3. Make sure the pillow has a plastic cover.
1. The histoplasmosis is resolving.
4. Keep a change of bed linens nearby in case
2. The client has disseminated histoplasmosis they are needed.
infection.
For clients with AIDS who experience night fever
3. This is a side effect of the medications given to and night sweats, the nurse may offer the client
treat AIDS. an antipyretic of choice before the client goes to
sleep rather than waiting until the client spikes a
4. The client probably has another infection that temperature. Keeping a change of bed linens and
is developing. - ANSWER -2. The client has night clothes nearby for use also is helpful. The
disseminated histoplasmosis infection. pillow should have a plastic cover, and a towel
may be placed over the pillowcase if diaphoresis
Histoplasmosis is caused by Histoplasma is profuse. The client should have liquids at the
capsulatum and usually starts as a respiratory bedside to drink.
infection in the client with AIDS and then
becomes a disseminated infection, with
enlargement of lymph nodes, spleen, and liver. A client with acquired immunodeficiency
